R. Jennelle

Prospective Study of Psychosocial Distress Among Patients Undergoing Radiotherapy for Head and Neck Cancer

PURPOSE To determine the prevalence of psychosocial distress among patients undergoing radiotherapy (RT) for head and neck cancer and to examine the association between depression and anxiety and demographic and medical variables. METHODS AND MATERIALS A total of 40 patients (25 men and 15 women) with nonmetastatic head and neck cancer were enrolled in this prospective study and underwent RT administered with definitive (24 patients) or postoperative (16 patients) intent. Twenty patients (50%) received concurrent chemotherapy. All patients completed the Hospital Anxiety and Depression Scale and Beck Depression Inventory-II instrument before RT, on the last day of RT, and at the first follow-up visit. The effect of patient-, tumor-, and treatment-related factors on psychosocial distress was analyzed. RESULTS The prevalence of mild to severe pre-RT depression was 58% and 45% using the Hospital Anxiety and Depression Scale-D and Beck Depression Inventory-II scale, respectively. The prevalence of severe pre-RT anxiety was 7%. The depression levels, as determined by the Hospital Anxiety and Depression Scale and Beck Depression Inventory-II instrument increased significantly during RT and remained elevated at the first follow-up visit (p < 0.001 for both). The variables that were significantly associated with post-RT depression included a greater pre-RT depression level, employment status (working at enrollment), younger age (<55 years), single marital status, and living alone (p < 0.05, for all). CONCLUSION The results of our study have shown that an alarming number of patients undergoing RT for head and neck cancer have symptoms suggestive of psychosocial distress even before beginning treatment. This proportion increases significantly during RT. Studies investigating the role of antidepressants and/or psychiatric counseling might be warranted in the future.

Late esophageal toxicity after radiation therapy for head and neck cancer.

The aim of this study was to determine the incidence of esophageal toxicity after radiation therapy for head and neck cancer.

Initial clinical experience with helical tomotherapy for head and neck cancer

To report a single‐institutional experience with the use of helical tomotherapy (HT)‐based intensity‐modulated radiotherapy (IMRT) for head and neck cancer.

Induction docetaxel, Cisplatin, and 5-Fluorouracil precludes definitive chemoradiotherapy in a substantial proportion of patients with head and neck cancer in a low socioeconomic status population.

Objectives:In this retrospective study we evaluate the tolerability and outcomes after induction chemotherapy for patients with predominately low socioeconomic status (SES) with locally advanced head and neck cancer (LAHNC). Methods:One hundred eighteen patients with LAHNC of the hypopharynx, larynx, oral cavity, or oropharynx began curative intent therapy with induction cisplatin (75 or 100 mg/m2), docetaxel (75 mg/m2), and 5-fluorouracil (750 mg/m2×5 d or 1000 mg/m2×4 d; continuous infusion) every 3 weeks (DPF) for a planned 2 to 3 cycles. All patients were to receive curative radiotherapy with concurrent systemic therapy. Associations were tested using &khgr;2 test, and survival estimates were calculated using the Kaplan-Meier method. Results:Most patients (75.4%) were of low SES. Induction DPF was delivered for a median of 2 cycles (range, 1 to 3) and 14% of the patients (n=17) died during induction DPF. After DPF, 38.2% of patients were unable to complete or receive planned definitive therapy. Overall 15.3% of patients died during therapy, and mortality was associated with a Karnofsky performance status <80 (P=0.04). At 2 years the locoregional control was 52.7%, whereas the distant metastases free rate was 72.6%, and the overall survival rate was 34.1%. Low SES patients were less likely to achieve locoregional control (P=0.05) or survive (P=0.08). Conclusions:In this population of LAHNC patients of low SES with a high tumor burden and poor performance status, use of induction DPF was associated with 15.3% mortality during therapy and precluded 38.2% of patients from initiating or completing planned definitive therapy.

Radiation-Associated Toxicities in Obese Women with Endometrial Cancer: More Than Just BMI?

Purpose. The study characterizes the impact of obesity on postoperative radiation-associated toxicities in women with endometrial cancer (EC). Material and Methods. A retrospective study identified 96 women with EC referred to a large urban institutions radiation oncology practice for postoperative whole pelvic radiotherapy (WPRT) and/or intracavitary vaginal brachytherapy (ICBT). Demographic and clinicopathologic data were obtained. Toxicities were graded according to RTOG Acute Radiation Morbidity Scoring Criteria. Follow-up period ranged from 1 month to 11 years (median 2 years). Data were analyzed by χ 2, logistic regression, and recursive partitioning analyses. Results. 68 EC patients who received WPRT and/or ICBT were analyzed. Median age was 52 years (29–73). The majority were Hispanic (71%). Median BMI at diagnosis was 34.5 kg/m2 (20.5–56.6 kg/m2). BMI was independently associated with radiation-related cutaneous (p = 0.022) and gynecologic-related (p = 0.027) toxicities. Younger women also reported more gynecologic-related toxicities (p = 0.039). Adjuvant radiation technique was associated with increased gastrointestinal- and genitourinary-related toxicities but not gynecologic-related toxicity. Conclusions. Increasing BMI was associated with increased frequency of gynecologic and cutaneous radiation-associated toxicities. Additional studies to critically evaluate the radiation treatment dosing and treatment fields in obese EC patients are warranted to identify strategies to mitigate the radiation-associated toxicities in these women.

A Systematic and Evidence-Based Approach to the Management of Vertebral Metastasis

Diagnosis and management of vertebral metastasis requires a systematic approach to patient identification as well as selection of appropriate therapy. Rapid identification and prompt intervention in the treatment of malignant epidural spinal cord compression (MESCC) is key to maintaining quality of life. This paper provides a series of tools as well as guidance in selecting effective and evidence-based therapy individualized to the specific patient.

In Regard to Dr Vapiwala

To the Editor: We read with great interest the Brief Opinion piece by Dr Vapiwala (1), and although we certainly agree with her sentiments on many points, there were some areas that should be further clarified for the sake of accuracy. Dr Vapiwala seems to rely heavily on the referenced work of Hern et al (2), who cite 8 different categories of “illegal” questions asked during the interview. We would like to call attention to the fact that at least 3 of the questions listed (age, gender, and ethnicity) are components that are already a routine part of the Electronic Residency Application Service (ERAS) application completed by each resident candidate. In addition, it is not “illegal” to ask any of these questions, although it might be unwise and, at times, in violation of the contract with the National Resident Matching Program. An example should help to clarify what we mean. If ethnicity were asked and then used to identify candidates who would contribute to the diversity of a program, that question is not only legal but also actively encouraged. On the other hand, if the answer is used to disqualify a candidate, that would be an illegal action. Asking the question is not illegal, but what one chooses to do with the answer determines the legality. Although race, religion, gender, and national origin are indisputably protected classes according to Title VII of the Civil Rights Act of 1964, many of the others listed are not. For example, the Age Discrimination in Employment Act as amended only applies to workers over 40 years of age and would, therefore, only apply to a vanishingly small number of resident applicants. There is no protected class status for arrest or conviction record, which incidentally is also a routine part of the ERAS application (3). Citizenship, or more precisely the legal right to work in the United States as a citizen or lawful resident, is a requirement for participation in a licensed activity such as medicine. It is also a component of the ERAS application. Discrimination based on sexual orientation is not a violation of federal statute. The relevant legislation (the Employment Non-Discrimination Act) has never cleared Congress,

Trends in Radiation Practices for Female Ocular Oncologists in North America: A Collaborative Study of the International Society of Ocular Oncology

Background: The aim of this study was to determine the known radiation exposure, attitudes, and consequent risk modifications among female ocular oncologists in North America who routinely administer radioactive plaque brachytherapy treatment and are members of the International Society of Ocular Oncology. Methods: Nineteen female ocular oncologists completed an anonymous 17-question radiation exposure survey. Results: Eleven of the participants chose to routinely wear lead protection during surgery; 8 did not. Fifteen of 19 participants reported using an unloaded “nonactive” template to prepare for plaque implantation. During pregnancy, 11 of 13 participants continued to perform plaque brachytherapy. Eight of these 11 undertook measures to decrease radiation exposure self-reported as lead wear and other. The average reported anxiety regarding fertility was 2.1 (SD, 2.2) on a scale from 1 to 10. Conclusion: This study corroborates prior literature that surgeons’ exposure to radiation during plaque brachytherapy is minimal. Nonetheless, there remains some anxiety regarding exposure risk to women, due to potential effects on fertility and fetal health. We found variability in exposure monitoring, required training, and precautions during pregnancy amongst this group of surgeons. Improved education and clearer pregnancy guidelines may equip female ocular oncologists with optimal knowledge regarding risk of radiation exposure.

Safety-Net Versus Private Hospital Setting for Brain Metastasis Patients Treated With Radiosurgery Alone: Disparities in Follow-Up Care and Outcomes

Stereotactic radiosurgery (SRS) alone is an increasingly accepted treatment for brain metastases, but it requires adherence to frequently scheduled follow‐up neuroimaging because of the risk of distant brain metastasis. The effect of disparities in access to follow‐up care on outcomes after SRS alone is unknown.

Development of a Radiation Oncology Resident Continuity Clinic to Improve Clinical Competency and Patient Compliance

Purpose To assess the impact of a radiation oncology resident continuity clinic (RCC) on patient compliance and residency education. Methods and Materials This is a retrospective review of all follow-up visits at a public safety net hospital in the 2016 calendar year. Previously, follow-up care was assigned to teams based on the disease sites treated by a single attending with the resident on a 1:1 rotation in the traditional apprenticeship model (TAM). On July 1, 2016, the department was restructured to a RCC model where patients were scheduled to be seen by the resident physician who performed the planning simulation of their radiation treatment. The number of no-show visits was compared before and after the restructuring. All residents completed a survey regarding their satisfaction on 20 aspects of faculty supervision, clinical environment, resident perception, and educational experience. Results A total of 1,896 follow-up visits were included in the analysis. The TAM had 907 follow-up visits, while the RCC model had 991 visits. The TAM had a no-show rate of 25.6% compared to the RCC model’s 16.4%. To estimate the impact of RCC on compliance, we employed a segmented linear regression with robust standard errors, which showed that the RCC improved clinic adherence by an absolute amount of 9.4% (p<0.02). Survey participants reported statistically significant improvement (p<0.05) in 8 areas, which include relationship with patients, confidence as a physician, and learning management of toxicities and treatment outcomes. Conclusion The RCC model is a feasible approach for follow-up care in a radiation oncology department in a safety net hospital setting. This model may improve patient compliance with appointments, strengthen the education of toxicity management, and promote the emotional well-being of trainees.